Q&A on SARS: Tomás Aragón of the UCB
Center for Infectious Disease Preparedness, on what we know
and what we can do

George Strait, Public Affairs |
10 April 2003

BERKELEY - In the past month,
a mysterious, highly contagious respiratory disease has rapidly
spread around the world, involving 16 countries. As of April
10, Severe Acute Respiratory Syndrome (SARS), which shares
many of its symptoms with other, more common respiratory illnesses
like colds or flu, had infected some 2,700 people and killed
111 people. An overwhelming majority of cases have been in
mainland China and Hong Kong. No cases have been reported on
the Berkeley campus.

To recommend measures to protect students, staff, and faculty
at Berkeley, Chancellor Robert Berdahl has appointed a SARS
task force. Among its members is Tomás Aragón, director of
the UC Berkeley Center for Infectious Disease Preparedness.
George Strait, assistant vice chancellor for public
affairs, sat down with Aragón to find out what we know about
SARS and what measures are possible to prevent its spread.

Q.Information is changing by the hour, but what do we know
about SARS?

A. What we know right now is that
the SARS virus is almost certainly from a family called coronaviruses.
The outbreak
was initially detected in Vietnam — a person who was
exposed to the index case in the Metropole Hotel in Hong Kong
traveled to Vietnam. Then there was an outbreak of infection
in the health care workers, and one of the clinicians in Vietnam
realized that this might be a bigger issue. That’s when
the World Health Organization (WHO) got involved in figuring
out what was happening in Hong Kong, in Vietnam, and then in
China.

As far as we can tell, this is a new virus. It’s a respiratory
tract infection that causes pneumonia and respiratory failure.
About one out of 10 persons with SARS develops respiratory
failure requiring ventilation. A smaller percentage of that,
about 3.5 percent of the total, have died so far.

We don’t now have effective treatment for SARS, and
it’s very transmissible. However, it’s not transmissible
in the same way as some other respiratory tract infections,
such as tuberculosis, or even like chicken pox or measles.
In these illnesses, you get aerosolization of the virus that
lasts in the air for hours so that the disease is very, very
infectious. In contrast, the SARS virus, as far as we can tell,
is spread primarily by large respiratory droplets, which are
not suspended in the air for a long time, so you really have
to have close contact with an infected person.

Q.Can SARS be spread by touching surfaces contaminated by
an infected person?

A. When somebody coughs or sneezes, they can contaminate
surfaces — tables, telephones, door knobs. So if people
touch these surfaces and then touch their nose or mouth, for
example, they can get infected. So, while it’s not as
infectious as influenza, that’s still pretty infectious.
And with a mortality rate of around 3.5 percent, if we assume
that most of the world’s population is going to be susceptible,
it really has the potential to make a lot of people sick and
cause a large number of deaths.

Q.Is there a diagnostic test?

A. As of today, there is not a diagnostic test. We hope within
a week or two we’ll have diagnostic testing available
at state labs so that if doctors think they see someone who
has SARS they can collect a specimen and send it to the state
health department to get it confirmed. That will be really
important for our control efforts. We will focus on people
we know are infected with the virus. Because the symptoms can
be so common, we don’t want to waste a lot of our public
health resources in worrying about people who don’t have
SARS.

Q.Until we do that, there is a definition to discover whether
or not a person has SARS. What is that definition, and how
bound by it should we be as we try to deal with people who
are sick?

A. The CDC has come up with what they call a “case
definition” to help us track how the infection is spreading.
The case definition is loose enough so that we can make sure
it [casts a wide enough net to identify cases and] help control
the spread of the infection. So the case definition that they’re
using is this: anybody who has a fever of greater than 38ºC,
or 100.5ºF, and has respiratory symptoms, and has either
come from a country where SARS has been identified (currently
China, Hong Kong, Vietnam, and Singapore) or has had contact
with somebody who had SARS.

If doctors can identify influenza or another condition in
a patient, then it’s unlikely that they have SARS. But
if we rule these out, you have what physicians call a diagnosis
of exclusion — you’ve ruled out the things that
we do know about and what’s left over is an undiagnosed
condition that meets the case definition. It’s then considered
a SARS case.

Q.Suppose somebody has just come back from Vietnam, has
sniffles, and is running a low-grade fever. What should they
do, and how should health care workers treat them?

A. It’s a good idea, in general, that anybody who has
a respiratory tract infection (since we don’t know exactly
what we’re carrying) should be careful that they’re
not transmitting it to others. So first, we need to practice
common sense rules that we all know but don’t always
follow. Common sense will reduce transmission of a lot of common
respiratory viruses.

For instance, people should cover their mouths when they cough,
preferably with a tissue, so they’re not easily contaminating
their hands. And we should all wash our hands frequently.

When patients arrive at a clinic with a respiratory tract
infection, they should be asked to put on a mask. By actually
covering the person who’s sick, you dramatically reduce
how infectious that person is. What you don’t want is
to have people in the waiting room infecting others. Patients
don’t come to the doctor with the expectation that they’re
going to leave with another disease. Actually, in two cases
reported in the New England Journal of Medicine, that’s
how people got infected. They were in the waiting room and
were infected by a patient who was there to see the doctor.

Q.So
someone who walks into an ambulatory care center and sees people
with masks on shouldn’t be afraid of them.

A. Absolutely! They should not be afraid of them. They should
say, “My doctor’s doing his or her job.”

Q.What about public health officials? Should they handle
SARS aggressively?

A. Health officials are struggling with this, just how aggressive
to be. I think health officials are always cognizant of the
fact that when they implement control strategies, it can affect
the economy, it can affect travel, and it can affect people’s
livelihoods. If you’re asking people to stay home and
not go to work, those are real issues. Health officials really
weigh all these issues carefully. In general, I think they’re
going to side on what they think is best for public health,
even if they know it’s going to have an economic impact.

As a society and as a world, we have to decide if we are going
to eradicate this or just try to slow its spread. Those are
two very different strategies. It may be that even if we decide
that we’re going to try to eradicate SARS — which
means recommending limitations of travel, being aggressive
in isolating people who are sick, preventing them from going
to work and infecting other people — in spite of your
best efforts, it still might spread.

On the other hand, if you don’t give it your best effort
and it spreads, you’ve lost the opportunity for eradication
once it’s become endemic.

If this becomes endemic in the world, we’re going to
hope that people are going to have some type of persistent
immunity, so the next time they get infected it won’t
be serious. The coronaviruses can actually re-infect people.

Q.If you don’t eradicate it, and it becomes endemic
in certain parts of the world, you haven’t really solved
any of these economic or travel issues, right?

A. Right, absolutely, and that’s what Hong Kong was
struggling with. People say, “No, no, we need to travel,
we need the tourism, we need the business,” and one of
the public health officials says, “Look, it’s happening
anyway, whether you like it or not, people are not going to
come here. We’re making a public health statement that
makes absolute sense, and you’re just going to have to
accept it.” We really need to deal with this now, because
if we don’t, there will be a longer period when travelers
won’t be able to return to areas where the outbreaks
have been occurring.

Q.On campus, what should we be doing?

A. It’s important for us not to have a “wait-and-see” attitude.
It’s important for us to be proactive in thinking through
the things that can happen here on campus. We want to educate
people on the basic things they can do to prevent getting infected
from general respiratory viruses. I think the basic stuff goes
a long way toward keeping people healthy. We want to get people
accustomed to the idea that you may be sitting on a bus and
see someone wearing a surgical mask, so just recognize that
this may become a regular occurrence, go with the flow, and
accept it. The day may come when you have to wear a surgical
mask, and you don’t want people stigmatizing you and
treating you differently.

I think we are going to have to make a cultural shift. In
Asia, people wear masks for other reasons, such as pollution,
so it’s not as much of an issue to see somebody with
a mask on. We may need to get used to some of that, at least
temporarily, until we see how this plays out. It may be that
if we don’t eradicate this thing, 20 years from now,
we hope, it’ll be a regular occurrence that doesn’t
cause a lot of illness because the population has developed
immunity. Until that time comes, we’re going to have
to go through a transition here where we may be doing things
that we’re not accustomed to.

Q.How are we preparing ourselves on campus?

A. The task force has been identifying the key issues that
they’re going to have to struggle with. One is what to
do about students who are going to be traveling abroad to programs
or to do research. The task force, right now, recommends following
current CDC guidelines on unessential travel to areas where
outbreaks have been occurring. We’ll revisit their policy
and guidelines repeatedly to see whether those should change.

The other issue is for the university to provide resources
and education for those who feel they must continue their work
abroad, so they can minimize the risk of getting infected or
bringing back an infection.

We also need to talk about what to do if someone develops
SARS in a campus residence hall. The details of that still
have to be worked out, but the university does have a public
health response team that deals with outbreaks in the student
setting, and they’ll evaluate the situation and make
recommendations to minimize the spread of disease.

To keep the campus informed, the Chancellor, the Tang Center,
and Public Affairs will put together information on the Web
and via e-mail to provide regular updates on how the situation’s
changing.

Q.So if you were the parent
of a student at Cal, how would you feel about how the university
is gearing up to protect
your student?

A. I think that Berkeley is being proactive in creating a
campuswide task force with representation from local public
health. It makes a lot of sense. I would be confident that
the university is doing everything it can.